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A. Duncan et al.
improved function of product, decreased 24-hour
and in-hospital mortality, and decreased complication rates [12, 20, 21].
Traumatic Brain Injury (TBI)
The initial evaluation of polytrauma patients
with suspected TBI should prioritize the assessment of neurological status. The Glasgow Coma
Scale (GCS) remains a valuable tool for quantifying the severity of TBI.The goal of preventing
secondary injury in traumatic brain injury (TBI)
is a crucial focus of evidence-based management. It is one of the major effects clinicians can
have to prevent worsening of patient outcomes.
The two major and preventable causes that are
seen to cause secondary injury are hypoxia and
hypotension.
Maintaining adequate cerebral perfusion pressure (CPP) by optimizing blood pressure and
oxygen delivery to the brain is essential. Cerebral
perfusion pressure = mean arterial pressureICP. Current guidelines support the use of
advanced monitoring techniques to guide the
management of TBI in polytrauma patients [22].
Intracranial pressure (ICP) monitoring is crucial
for early detection and management of intracranial hypertension, which can lead to secondary
brain injury. Classical recommendations per the
Brain Trauma Foundation recommend maintaining an ICP of ≤22. However, more recent studies
suggest that a patient specic ICP goal is more
correlated with improved outcomes [23, 24].
There has recently been questioning if agents like
hypertonic saline or mannitol are benecial.
While they have been shown to decrease ICP,
there appears to be no benet in mortality or neurological outcome with them [25–27].
Two recent randomized control trials evaluated the utility of using prophylactic hypothermia
in severe TBI. They differed slightly with one
using hypothermia in patients with elevated ICP
and the other study performed this in patients
without elevated ICP [28, 29]. While prophylactic hypothermia was successful at decreasing
ICP, but at the cost of increased mortality and
worst neurological outcomes [28, 29]. Further,
patients with TBI that present with accidental
hypothermia are found to have signicantly
higher rates of mortality [30].
Surgical Interventions: In select cases of
severe TBI, surgical interventions like decompressive craniectomy have gained prominence as
a means to reduce intracranial pressure and prevent herniation. Some data suggests that use of
decompressive craniectomy can improve outcomes, particularly in patients with refractory
intracranial hypertension [31, 32]. In contrast, the
DECRA study showed while early decompressive craniectomy decreased intracranial pressure,
it was associated with worst 6-month mortality
[33]. However, the correct patients that would
benet most from decompressive craniectomy
and have meaningful quality of life are still being
investigated.
Hypoxia and hypotension are associated with
poorer outcomes in TBI patients, emphasizing
the importance of oxygenation and hemodynamic
stability. Addressing injuries that cause hemodynamic instability becomes a priority in patients
with TBI. Additionally, avoiding hypercapnia
and maintaining normocapnia, as well as managing temperature to prevent hyperthermia, have
been shown to reduce secondary injury. Close
neurological monitoring, the use of advanced
neuromonitoring techniques, and a multidisciplinary approach are integral to the evidencebased prevention of secondary brain injury in
TBI patients.
Abdominal Injuries
Damage Control Laparotomy
Damage Control Laparotomy (DCL) continues to
be a fundamental part of trauma surgery. DCL
focuses on controlling hemorrhage and contamination while minimizing operative time to save
the physiologic reserve of the patient. Typical
indications for DCL are as follows: metabolic
acidosis (pH<7.2), hypothermia (<35°C), coagulopathy, patients who are unstable and operation
will last longer than 2hours, or patients that will
require further intra-abdominal surgical evaluation at a later time [34].
22 Surgical Decision-Making intheManagement ofPolytrauma Patients
281
Combination of improvements in temporary
abdominal closures and hemostatic resuscitation
over the past decade have made the DCL more
efcient and decreased the rate of complications
we see. As stated above the focus of DCL is rst
controlling hemorrhage and second, contamination. Hemorrhage should be controlled with
timely repair, packing, simple ligation, or temporary shunts. Hollow viscus injuries should be
resected and anastomosis left for the time of
denitive repair. Multiple different methods of
temporary negative pressure systems exist commercially or can be fashioned with equipment
readily available in the operating room, to serve
as an optimal method of temporary abdominal
closure. The initial portion consists of a porous
plastic covering that allows extraction of uid
while preventing the formation of adhesions. In
authors’ experience, a sterile X-ray lm cover
with perforations works very well, is inexpensive and readily available. Foam or operating
room sterile towels are then placed with an eventual occlusive dressing overtop with airtight
drains being laid in bilateral gutters. Negative
pressure is then typically applied between 100
and 150mmHg. There are also readily available
commercial products that include all parts in a
single package. Once the patient has been
removed from the operating room, focus should
be placed on further resuscitation, hemodynamic
stability, correction of acid/base, electrolyte
abnormalities and rewarming.
After the patient has been stabilized and physiologically optimized in the ICU setting, they
should be considered for return to the operating
room either for repeat exploration or denitive
repair. While multiple centers and surgeons will
opt for an arbitrary 48-hour period, we recommend returning to the operating room once the
patient is physiologically optimized.
With the evolution of and utilization of the
open abdomen strategy, it is important to keep in
mind closure of the abdomen. Delay in closure is
associated with increase in ventral hernias,
enterocutaneous or entero-atmospheric stulas,
and loss of abdominal domain. One recent study
showed that closure of the abdomen within
8days can minimize complications [35].
Non-operative management
High quality data shows the benet of nonoperative management (NOM) within abdominal
trauma in certain clinical situations [36, 37]. The
current standard of care for the majority of
patients with blunt abdominal trauma who are
hemodynamically stable without peritonitis is to
pursue further radiological work up with computed tomography. However, patients who are
hemodynamically unstable or exhibit peritonitis
on examination should undergo surgical intervention, as stated above.
The management of transient responders
involves institutional resources (availability of
interventional radiology or surgical capabilities)
to address the cause of hemodynamic instability.
In facilities with quick access to interventional
radiology, stable patients with solid organ injuries of advanced grading will often be effectively
treated with angioembolization or other interventional radiologic interventions. Our institution
uses the American Association for Surgery of
Trauma grading of solid organ injuries.
Patients with known injuries who are being
managed with NOM require hospital admittance
with close monitoring for changes in the patient’s
clinical status. There are no current recommendations on the frequency of monitoring; however, it
typically consists of serial laboratory values,
NPO status, initial short-term limitations of activity, and repeat abdominal examinations.
Clinicians also need to maintain a high index of
suspicion for injuries that are often missed on the
patient’s initial CT scan, including hollow viscus
injuries and diaphragmatic injuries. Furthermore,
patients who experience deterioration in their
clinical status should undergo operative intervention as quickly as possible.
Thoracic Injuries
Injuries resulting from trauma stand as the primary global cause of mortality. In the United
States, thoracic trauma contributes to as much as
35% of trauma-related fatalities, involving a
diverse array of injuries resulting in signicant
morbidity and mortality [38, 39]. Thoracic trauma
is seen in approximately two-thirds of trauma
patients and with varying degrees of severity,
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A. Duncan et al.
often ranging from simple rib fractures to more
complex penetrating injuries. Thoracic trauma is
broadly categorized as blunt or penetrating
trauma. Blunt chest trauma is the most common,
accounting for 80% of incidents, with less than
10% needing any form of surgical intervention vs.
15 to 30% in patients that sustained penetrating
chest injuries [38]. However, blunt chest trauma
directly contributes to 20 to 25% of trauma deaths
[38]. Mortality rates, second only to head injuries,
emphasize the critical signicance of prompt and
effective initial management. Timely diagnosis
and treatment can prevent a signicant number of
these fatalities [38].
The management of chest trauma can be categorized into three specic tiers of care: prehospital trauma support, in-hospital or emergency
room trauma support, and surgical trauma support [36]. Recognizing thoracic injuries at each
care level is pivotal for subsequent outcomes.
The initial resuscitation and management of a
patient with chest trauma adhere to protocols outlined in Advanced Trauma Life Support (ATLS)
[5]. Following a primary survey, the focus is on
promptly excluding or addressing immediately
life-threatening injuries, such as tension pneumothorax, massive hemothorax, ail chest, cardiac
tamponade, aortic injury, and tracheobronchial
disruption.
Prehospital support: The initial evaluation
of the trauma patient begins with the primary
survey, which is an essential step in recognizing immediately life-threatening conditions
such as tension pneumothorax, pulmonary contusion, massive hemothorax, and cardiac tamponade. General inspection of the thorax for
asymmetry; palpation for tenderness, crepitus,
and ail segments; percussion; and auscultation [sensitivity of 90% and specicity of 98%
will aid in identifying life-threatening conditions such as tension pneumothorax, which
may necessitate immediate intervention such
as needle decompression or tube thoracostomy
[40, 41]. Given that tension pneumothorax
stands as the most frequently reversible cause
of death in trauma patients experiencing cardiac arrest, prompt and accurate assessment is
crucial [42–44].
In-hospital support: The assessment of
patients with thoracic trauma commences with
Advanced Trauma Life Support (ATLS) and subsequently utilizes diverse imaging methods contingent on the initial symptoms observed. Swift
intervention is imperative for life-threatening
injuries identied during the initial trauma
assessment.
Ever since its initial formal description nearly
ve decades ago, the emergency department thoracotomy (EDT) has remained a subject of debate
for many years [45]. Research indicates that outcomes depend on the mechanism of injury, anatomic location of injury, and the presence of signs
of life on arrival [39]. Dened by the American
College of Surgeons Committee on Trauma in
2001, signs of life are considered present with any
of the following: pupillary response, spontaneous
ventilation, presence of carotid pulse, measurable
or palpable blood pressure, extremity movement,
or cardiac electrical activity [45]. In penetrating
chest trauma, the survival rate after resuscitative
thoracotomy is 8.8%, contrasting with 1.4% in
blunt chest trauma. Notably, patients with penetrating chest trauma and signs of life upon arrival
have an overall survival rate of 19.4% in contrast
to 4.6% overall survival in blunt chest trauma
with signs of life present upon arrival [46]. There
have recently been some suggestions as to different indications in pediatric patients compared to
adult patients [47, 48]. Adult and pediatric patient
indications/contraindications for resuscitative
thoracotomy include [49–51]:
Adult Indications:
Salvageable postinjury cardiac arrest:
• Patients sustaining witnessed penetrating
trauma with <15minutes of prehospital CPR.
• Patients sustaining witnessed blunt trauma
with <5minutes of prehospital CPR.
Persistent severe postinjury hypotension
(SBP≤60mmHg) due to:
• Cardiac tamponade.
• Hemorrhage—intrathoracic, intra-abdominal,
extremity, cervical.
• Air embolism.
22 Surgical Decision-Making intheManagement ofPolytrauma Patients
283
Adult Contraindications:
• Penetrating trauma: CPR>15minutes and no
signs of life (pupillary response, respiratory
effort, or motor activity).
• Blunt trauma: CPR>5minutes and no signs
of life or asystole.
Pediatric Indications:
• Pediatric patients with penetrating thoracic or
abdominopelvic injury and signs of life on
presentation.
• Pediatric patients with blunt injury and signs
of life on presentation.
Pediatric Contraindications:
• Pediatric patients with penetrating thoracic or
abdominopelvic injury without signs of life on
presentation.
• Pediatric patients with blunt injury without
signs of life on presentation.
Hemothorax and pneumothorax are the most
common injuries frequently encountered in thoracic trauma. These can be denitively managed
through the use of a chest tube in 80% of cases
[39]. Approximately 10% of all trauma patients
and 30% of those with chest trauma exhibit rib
fractures [43]. Initial management in patients with
three or more rib fractures entails ensuring adequate analgesia, thoracostomy drainage if
required, and pulmonary hygiene. Effective pain
control is paramount and involves a multimodal
approach beginning with acetaminophen and
NSAIDs, with opioids administered on an asneeded basis. Regional anesthesia, such as epidural anesthesia can be used as a step-up approach
for patients with multiple or displaced rib fractures, and for those with pain unresponsive to
pharmacologic management [45]. Surgical rib
xation is typically performed within 48 to
72 hours of the injury and is reserved for cases
where adequate pain control cannot be achieved
and for patients facing impending respiratory failure or unable to wean off ventilatory support [39].
Certain patients require urgent or emergent operative intervention. Thoracotomy performed in the
operating room is indicated for various conditions in thoracic trauma including massive hemothorax with blood loss ≥1500 mL initially
or > 200 mL/hour of chest tube output over
2–4 hours, cardiac tamponade, great vessel
injury, signicant air leak persisting after thoracostomy placement, conrmed tracheobronchial
injury, and open pneumothorax [34]. As minimally invasive techniques have become more
popular, video-assisted thoracoscopic surgery
(VATS) has been increasingly used in favor of
thoracotomy in hemodynamically stable trauma
patients, leading to faster recovery, reduced postoperative pain, and greater visualization of the
entire pleural place for diagnosing and treating
commonly missed injuries such as retained
hemothoraces and diaphragmatic lesions [38, 52,
53].
Orthopedic Management
Orthopedic injuries are a signicant source of
hemorrhagic shock and blood loss for polytrauma patients and must be considered and
addressed in the acute setting. It has been estimated that a signicant amount of musculoskeletal injuries are missed during the primary
survey [54].
Pelvic fractures can cause a signicant amount
of blood loss without external physical signs
other than vital changes. Open long-bone fractures also must be recognized and addressed as
they have major vascular supply and will have no
means of self-tamponade. Orthopedic trauma
surgery has also taken a similar paradigm shift
from what was previously known as “Early Total
Care” (ETC) to what is now standard of care as
“Damage Control Orthopedics” (DCO). The
notion that the polytrauma patients with signicant musculoskeletal injuries were considered
too physiologically unstable to undergo any
major orthopedic surgery was questioned by the
Bone et al. study in 1989 [55]. This landmark
study found that early xation of all long-bone
fractures within 24hours of initial injury led to
reduced morbidity among patients, including
284
A. Duncan et al.
reduced pulmonary complications and length of
ICU and hospital stay [55]. The term “Early Total
Care” was shortly established following this
study, and it referred to denitive fracture surgery
within 24–48hours for all long-bone fractures in
a polytrauma patient. The practice of ETC was
challenged as studies that followed found a rise
in pulmonary complications and multiorgan dysfunction observed in polytraumatized and physiologically unstable patients that were managed
using this approach. The studies described these
complications as arising from the “second hit” or
inammatory response associated with fracture
surgery [56]. This led to the emergence of
“DCO.” Modeled after the concept of “damage
control surgery,” “DCO” emphasizes that a certain subgroup of patients require further resuscitation and medical optimization prior to
undergoing denitive fracture surgery and thus,
temporizing measures such as external xation of
fractures can lead to more favorable outcomes in
such patient groups [57]. Current recommendations though are for open fractures to be taken to
the OR within 24hours for initially debridement
and possible early closure [55].
Infection Prevention andAntibiotics
Prophylactic Antibiotics
Prompt antibiotic use is important in indicated
clinical settings, while not overusing to create
antibiotic resistance is also essential. The usage
of antibiotics must still be driven by the etiology
of disease process that the patient is experiencing. Patients who have open fractures, lacerations, or concern for viscus injuries justify the
usage of antibiotics. The majority of trauma centers will have intuitional protocols for recommended antibiotic and dosages given their area
specic microbiome. Those who are being taken
to the operating room for intervention also justify
the use of prophylactic antibiotics given within
one hour prior to incision. In regard to doing
open abdomen, evidence shows that there is a
benet in prompt prophylactic administration of
antibiotics and early discontinuation in appropriate patients [58].
Multidisciplinary Care
Team Collaboration
The polytrauma patient often presents with injuries spanning various medical specialties, necessitating a comprehensive, multidisciplinary
treatment approach. The optimal approach to caring for multiply injured patients requires a multidisciplinary team, including but not limited to
trauma surgeons, orthopedic surgeons, anesthesiologists, intensivists, neurosurgeons, maxillofacial surgeons, ophthalmologists, diagnostic/
interventional radiologists, and various other specialists [59]. Vertical integration of various teams
within the healthcare system is essential in the
delivery of care and management of the polytrauma patient. This includes integration of nursing, advanced practice providers, pharmacists,
blood bank, case managers, social workers, clinical psychiatry, and physical and occupational
therapists to name a few.
This comprehensive approach to managing
polytraumatized patients spans across various
disciplines, commencing in the prehospital phase
with the involvement of early responders and
emergency medical service (EMS) personnel. It
is these highly specialized prehospital teams who
are tasked with the initial assessment, stabilization, and transportation of the polytrauma patient
to the nearest trauma center equipped to address
their needs [60]. Given the substantial volume of
trauma patients, accurate triage is crucial, with
over 90% best served inlocal community hospitals [60]. The remaining 10%, comprising
severely injured individuals necessitating higher
level of care at Level I and II trauma centers,
demands a multidisciplinary approach to enhance
overall clinical outcomes [60]. When in the
trauma bay, effective, closed-loop communication and level-appropriate division of tasks
among members of the team is of crucial
importance in effectively managing a polytrauma
patient [61]. Team members such as anesthesiologists play a major role in both the peri-operative
and intraoperative care of the polytrauma patient.
Ensuring that recommended large bore peripheral IV access (or when not possible adequate
vascular access, intraosseous needle, central
22 Surgical Decision-Making intheManagement ofPolytrauma Patients
285
venous line, or arterial line for hemodynamic
monitoring) has been obtained for resuscitation
and infusion of intravenous uids, blood products, and medications is a task that can be accomplished by trained emergency room providers
while the trauma surgeon can focus on the operative management aspect of the patient. Once the
patient has been stabilized, the intensivists not
only provide additional critical care to trauma
patients but are also intimately involved in consulting and coordinating care between different
members of the healthcare team. Thus, successful integration of a collaborative, multidisciplinary team approach in managing the
polytrauma patient is crucial for minimizing
complications, lowering mortality rates, and
expediting recovery following injury [59].
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Decision-Making inComplex
Dento-Alveolar Trauma
intheMaxillofacial Region
LumnijeKqiku andKurtAloisEbeleseder
23
Introduction
General Remarks
Maxillofacial trauma, skull fractures, and dentoalveolar injuries are frequently found in blunt and
penetrating trauma patients.
About 50% of isolated cases of traumatic dental injuries occur in children and teenagers, 19%
in girls, and 33% of all boys are affected.
Dento-alveolar trauma has multiple etiologies
including trafc collisions, sports injuries and
falls, assaults, or industrial mishaps [1–3].
Proper decision-making on the treatment of
dento-alveolar injuries is necessary to avoid serious long-term morphologic, functional, and aesthetic consequences. In addition to soft tissue
injuries, dental trauma is the most common facial
trauma in the maxillofacial region and primarily
affects the anterior region of the teeth [4–7].
In clinical situations with polytraumatized
patients showing multiple facial, orbital, and
skull fractures, bleeding, dental avulsions, fractures of the alveolar process, intrusions, and
severe intraoral soft tissue injuries, surgical
L. Kqiku (*) · K. A. Ebeleseder
Department of Dental Medicine and Oral Health,
Division of Restorative Dentistry, Periodontology and
Prosthodontics, Medical University of Graz,
Graz, Austria
e-mail: lumnije.kqiku@medunigraz.at;
kurt.ebeleseder@medunigraz.at
decision- making is very important. The decision
to perform denitive treatment during emergency
or subsequently, once the major and high-risk
injuries have been taken care and swelling has
subsided, is a matter of intuition, patient’s physiology, and overall clinical status. Tooth avulsion,
on the other hand, needs to be treated properly
and immediately [8].
In fractures of the alveolar process, a quick
decision should be made between manual reposition/splinting and open surgery (Figs. 23.1 and
23.2).
This means that for complex trauma, early
recognition of all injuries is necessary for the
decision between closed treatment (nasal tampons, intermaxillary xation, rigid and exible
splints for dental injuries) and open treatment
(surgical intervention).
Facial fractures such as nasal bone fractures,
naso-orbito-ethmoid complex fractures, orbital
fractures, zygomaticomaxillary complex fractures, Le Fort fractures (Le Fort type 1,2,3), and
mandibular fractures (body, symphysis mentalis,
ramus, condyle, coronoid process, alveolar crest)
are the most common injuries in maxillofacial
emergencies. Dento-alveolar injuries are associated with all types of facial trauma, and surgical
decision-making should be guided by clinical
scenario.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
R. Lati (ed.), Surgical Decision-Making, https://doi.org/10.1007/978-3-031-67391-7_23
289
290
Figs. 23.1 and 23.2 Alveolar process fracture/manual reposition and splinting immediately after trauma
L. Kqiku and K. A. Ebeleseder
Classication ofDento-Alveolar
Injuries
The most commonly used classication system
for dental trauma is Andreasen’s classication
(accepted by the WHO in 1972 and propagated
by the International Association of Dental
Traumatology, IADT) which is applied to both
primary and permanent teeth [9]. It distinguishes
between 4 types of fractures (crown fracture,
crown root fracture, root fracture, and fracture of
the alveolar process) and 6 types of luxations,
respectively, dislocations (concussion, subluxation, lateral luxation, extrusion, intrusion, and
avulsion).
This means that dento-alveolar injuries are
described as syndromes. A more analytic classication describes the tooth as composed of ve tissues that can also be injured independently from
each other [10, 11]. Thus, any injured tooth is
described in ve aspects: Dental Hard tissue,
Endodontium, Periodontal ligament, Alveolar
bone, and Gingiva.
By this method, also uninjured aspects are
described automatically (Table23.1 depicts this
classication).
Fracture injuries of the dental hard tissues
comprise crown fracture, crown root fracture,
and root fracture (Fig. 23.3), while the
Endodontium (dental pulp) can be affected
together with all forms of dento-alveolar injuries.
It can be injured in the form of an indirect expo-
sure (dentin fracture), a direct exposure to the
oral cavity, an internal exposure to the injured
periodontal ligament (in root fractures), a strain,
a contusion, or a separation (Fig.23.4). On the
other hand, the Periodontium is affected in so-
called Luxation injuries.
Six injury types with different healing patterns
can be distinguished:
Concussion
A slight injury to the periodontal ligament
with edema and partial bleeding but without
mobility of the affected tooth.
Subluxation
An injury with partial rupture of the periodontium structures accompanied by lip swelling and
gingival sulcus bleeding.
Extrusion
An injury to the tooth characterized by a subtotal rupture of the periodontal ligament resulting in partial displacement of the tooth out of its
socket.
The affected tooth is elongated with high
mobility to axial direction, accompanied by
strong gingival sulcus bleeding and possible rupture of the papillae. The resulting hematoma
pushes the tooth far out of the alveolus (Fig.23.5).